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Run: Transitional Care Management Documentation Template

Track Transitional Care Management documentation in one place, including discharge details, 2-business-day contact, face-to-face timing, and billing support ...

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Patient and Discharge Details

Patient Identifier (required)

Enter the internal medical record number or other approved patient identifier. Do not enter SSN.

Date of Discharge (required)

Select the date the patient was discharged from the qualifying facility.

Discharge Setting (required)

Other Discharge Setting

Interactive Contact Within 2 Business Days

Was interactive contact completed? (required)

Date of Interactive Contact

Interactive Contact Method

Completed within 2 business days of discharge?

Face-to-Face Visit Timing

Was the face-to-face visit completed? (required)

Date of Face-to-Face Visit

TCM Billing Code (required)

Select the code being supported by this documentation.

Visit occurred within the required window?

Clinical Follow-Up and Documentation

Medication reconciliation completed?

Care plan updated?

Follow-up Notes

Document any relevant follow-up actions, barriers, or exceptions. Avoid unnecessary PII.

Documentation complete and ready for billing review? (required)

Confirm that the record is complete and supports the selected TCM code.

Yes No N/A

Attestation

I attest that this documentation accurately reflects the transitional care management services provided and supports the selected billing code.

Documented By (required)

Enter the name or approved identifier of the staff member completing this form.

Documentation Date (required)

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Email (required)

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